Although it is difficult to predict who will attempt suicide, increased risk is associated with suicidal ideation or plans, non-suicidal self-injurious behaviors, and suicide attempts (Fosse et al., 2017). Two of the strongest predictors of suicide risk are mental illness and substance abuse (WSDOH, 2016).
Increased risk is also associated with gender, lack of support systems, genetic liability, childhood experiences, and the availability of lethal means. Individuals at a greater risk for completed suicide have been found to be male, older, and impulsive, have multiple physical ailments, a history of prior suicide attempts, psychiatric illness, violence, or a family history of suicide (Hassamal et al., 2015).
Attempts to explain, predict, and prevent suicide are limited due to its statistical rarity—suicide is exceedingly rare in comparison to associated risk factors. There are a great many people who abuse alcohol, the majority of whom do not commit suicide; hence the positive predictive value of these risk factors is low. Nevertheless, certain groups have higher suicide attempt or completion rates than the general population:
Although a large proportion of suicides could be avoided with effective treatment of mental disorders, 50% to 75% of those in need receive inadequate treatment. The under-recognition of mental conditions seriously limits the potential to identify and appropriately treat individuals at risk for suicide (DVA/DOD, 2013).
Risk Factors for Suicide
Suicide is overrepresented in people with mental illness (Fosse et al., 2017); over 90% of suicide victims have a diagnosable mental health and/or substance use disorder (DVA/DOD, 2013). The odds for suicide in severe depression, schizophrenia, and bipolar disorder are approximately 3 to 10 times that of the general population, with a higher increased risk in males than females. Despite this, mental illness is a poor predictor of suicidal ideation and behavior since suicide does not occur in 95% to 97% of all cases (Fosse et al., 2017).
In psychiatric inpatients, an array of risk factors for suicide has been identified. A person admitted for inpatient treatment in a specialized mental health facility has a 50- to 200-times increased suicide risk compared to the population at large. In two meta-analyses that included 42 studies and close to 3,500 suicide completers, central suicide risk factors were:
In addition to the risk associated with alcohol and substance abuse, a poor social network and social withdrawal, command hallucinations, delusions, diagnosis of mental disorders other than depression are thought to increase risk. This can include bipolar disorder and schizophrenia, coexisting significant physical illness, family history of mental illness, multiple admissions to inpatient treatment, unplanned discharge, and prescription of antidepressants (Fosse et al., 2017).
Impulsivity and disinhibition are overarching issues related to suicidal ideation and behaviors. In fact, angry impulsivity has been repeatedly identified as a risk factor for suicidal behavior. Although impulsivity is found in a wide range of diagnoses, it is highly associated with bipolar disorder, substance abuse, and certain personality disorders as well as a history of early child abuse (Fawcett, 2012).
Preventing Suicide in All the Wrong Ways
Despite the increased risk of suicidal ideation and behaviors in people with mental health disorders, mental health advocates regularly overstate the prevalence of suicide and suicide attempts among persons with mental illness. At the high end, the National Alliance on Mental Illness claims, “More than 90% of youth suicide victims have at least one major psychiatric disorder.” Mental Health America, a trade association for providers of mental “health” services, estimates “30% to 70% of suicide victims suffer from major depression or bipolar (manic-depressive) disorder.”
Suicide is not always the irrational act of a sick mind. Mental illness in people who commit suicide is often diagnosed after the fact. After someone takes his or her own life, we look for a cause. If they take their life after losing their spouse or job, received a bad grade in school, or received a new medical diagnosis, we chalk it up to depression and put the suicide in the mental illness column.
In spite of being overstated, it is clear that suicide does disproportionately affect people with mental illness. Studies looking at the prevalence of suicide among the seriously mentally ill, as well as studies of the prevalence of serious mental illness among those who attempt suicide, found about 5,000 of the 38,000 suicides (about 14%) were in people with serious mental illness. This is three times as high as the general population.
Source: DJ Jaffe, Preventing Suicide in All the Wrong Ways, 2014.
Illness, stressful life events, and certain medical conditions increase vulnerability and are associated with an increased risk for suicidal ideation and behavior. This can include chronic pain, cognitive changes that make it difficult to make decisions and solve problems, and the challenge related to long-term conditions and limitations (HHS, 2012).
Trauma can also be a risk factor for suicide. Although some individuals who experience trauma move on with few symptoms, many—especially those who experience repeated or multiple traumas—suffer a variety of negative physical and psychological effects. Trauma exposure has been linked to later substance abuse, mental illness, increased risk of suicide, obesity, heart disease, and early death (SAMHSA, 2011).
Co-morbid conditions may increase the likelihood that a suicide attempt becomes a completed suicide. For example if a person with a chronic condition such as hepatitis C swallows a bottle of acetaminophen, they are likely to suffer severe liver damage. By the same token, a person with severe anemia may not survive a suicide attempt involving a significant loss of blood.
Immigrants might have higher rates of psychopathology and suicidal behavior than the host populations, due to exposure to the stress of the migrating to an unfamiliar country. Severing links with their country of origin, the loss of status and social network, a sense of inadequacy because of language barriers, unemployment, financial problems, a sense of not belonging, and feelings of exclusion can affect a person’s desire to enter into a relationships with others, and cause a variety of psychiatric disorders such as depression, anxiety, post-traumatic stress disorder, addiction to alcohol and drugs, and lead to loneliness and hopelessness, and suicidal behaviors (Ratkowska & De Leo, 2013).
Social isolation can cause a person to live a condition similar to bereavement, caused by the loss of their previous social structure and culture. The most missed aspects are the language (especially colloquial language and dialect), attitudes, values and social support networks. The pain for these losses is a natural consequence of emigration. However, if the suffering causes significant distress or impairment and lasts for a long period of time, professional support may be necessary (Ratkowska & De Leo, 2013).
Migration poses a risk not only for immigrants but also for the families who remain in the country of origin. For example, it has been observed that the next of kin of Mexican immigrants in the United States were at greater risk of suicidal ideation and suicide attempts than Mexicans without a family history of emigration. Emigration can weaken family ties, lead to feelings of loneliness and insecurity, and increase the risk of suicide among family members who remain at home (Ratkowska & De Leo, 2013).
Immigrants from predominantly collectivist societies may face serious problems of adaptation. This could result in a real or perceived lack of adequate social support system, disparity between expectations and reality, and low self-esteem. Many immigrants undergo radical changes in their social status and may also be subject to discrimination. This could be an additional risk factor for suicide, as evidenced by one of the U.S. studies where immigrant’s suicide rates were positively correlated with the negative words used by the majority to describe their ethnic group (Ratkowska & De Leo, 2013).
In most studies conducted in Europe, America, and Australia, the highest risk of suicide was found in immigrants from northern Europe (including the United Kingdom, Ireland, and Finland), and Eastern Europe (especially from Russia and Hungary). The lowest risk was found in immigrants from southern Europe and the Middle East (Ratkowska & De Leo, 2013).
With regard to immigrants from Asian countries, the risk of suicide seems generally low for men but appreciably higher for women. The rates vary, therefore, not only in relation to the country of origin but also for sex of the immigrant. For example, in a study conducted in the United States, Asian, black, and Hispanic men had the lowest risk of suicide, while non-Hispanic white and Asian women had higher risk than the host population (Ratkowska & De Leo, 2013).
The high suicide rates among immigrants from Northern and Eastern Europe might be partly explained by the high alcohol consumption typical of these countries. For example, there is a significant correlation between alcohol consumption and suicide in Finland; Finnish immigrants who died by undetermined causes of death in Sweden also tend to have high alcohol levels in their blood. A similar trend was found in Russia, where suicide rates related to alcohol abuse are very high, and among Russian immigrants who died by suicide in Estonia (Ratkowska & De Leo, 2013).
The low rates of suicide among immigrants from southern Europe, the Middle East, and Asia may be due to some protective factors, such as the strong influence of traditional values, family, and religious beliefs. These countries are more collectivist, have strong family ties and a strong group identity outside their country of origin. Both in Catholic and Muslim countries, religion may be a strong deterrent to suicide, which is considered a sin in the Catholic religion and is forbidden by Islamic law. The protective role of religion could also depend on the ties with the religious community, which might represent a strong source of social support (Ratkowska & De Leo, 2013).
Among asylum seekers, those at higher risk for suicide are young, male, low income, with past traumatic experiences, and lack of social support. Refugees and asylum seekers often have several of these risk factors. Refugees are perhaps the most vulnerable group of all immigrants: they are often fleeing war, torture, and persecution, and suffering with PTSD, depression, and anxiety. Lack of adequate preparation, the way in which they are received in the destination country, poor living conditions, and lack of social support and isolation usually add to these vulnerabilities. Refugees may also feel guilty for leaving the loved ones at home or for their death. The sense of guilt, together with isolation and pathologic symptoms due to trauma, may be a strong risk factor for suicide (Ratkowska & De Leo, 2013).
Diagnostic Dilemma: Psychosis or Post Traumatic Stress Disorder
A 32-year-old black African, Muslim woman with a history of both PTSD and psychosis presented to mental health services for the first time with a history of auditory and visual hallucinations, persecutory delusions, suicidal ideation, recurring nightmares, hyper-arousal, and insomnia. She reported seeing blood on the walls, men in white following her, and hearing voices saying that some men were coming to get her. These symptoms were worse at night. She became very distressed and troubled to the point of wanting to end her life.
Her background history suggested co-morbid PTSD. Twelve years ago, she saw her family (parents, sisters and brother) being killed during the civil war in her birth country in Africa. Her clinical PTSD symptoms, such as the recurring nightmares, hyper-arousal, and insomnia, began shortly afterwards. Eight years later, she came to the United Kingdom as an asylum seeker. During her first few years in the UK, she had no social support, was unable to speak English, experienced homelessness and was unsuccessful in gaining asylum. Her auditory and visual hallucinations and persecutory delusions started at this time. A few months before her first contact with mental health services, her psychotic symptoms and PTSD features became more frequent and intense. With no stable relationship she became pregnant and visited her general practitioner who referred her to our first-episode psychosis unit.
Upon admission, she presented as well-kempt yet she appeared distressed. She was withdrawn and quiet and there was some delay in her responses to questions. She was tearful and her mood was low but reactive. She described vivid and clear auditory and visual hallucinations and persecutory delusions. Her medical psychiatric, personal, and family histories were unremarkable. A physical examination, neurological examination and brain magnetic resonance imaging (MRI) scan were normal. The results of our routine blood investigations were in the normal range, and a pregnancy test was positive. At our clinical interview, she clearly fulfilled the criteria for PTSD and psychotic disorder not otherwise specified.
Because of the intensity of her symptoms, her distress and suicidal ideation, our mental health team recommended ongoing hospitalization. She was started on trifluoperazine* (5 mg/day) and cognitive-behavioral therapy for psychosis. She also started a prenatal follow-up. She self-reported a partial improvement in her clinical picture and her psychotic symptoms gradually resolved over a three-week period, although they occasionally resurfaced when she was under stress or whenever her medication compliance lapsed. She was discharged from hospital and is now living in temporary accommodation funded by local services and waiting for her asylum re-application to be processed. She continues to have ongoing PTSD symptoms associated with the initial tragic event as persistent remembering of the stressor event with recurring and vivid memories, nightmares, hyper-arousal and initial insomnia. She also avoids circumstances resembling the initial stressor event, such as wars and violence.
* Trifluoperazine (Stelazine) is a typical antipsychotic primarily used to treat schizophrenia. It is part of a class of drugs called phenothiazines.
Source: Coentre & Power, 2016.